Monday, June 22, 2015

In which I steal a title: Is medicine a scientific enterprise?

A week ago, I attended the Center For Inquiry Reason for Change Conference, where I participated in a panel on—what else?—alternative medicine with—who else?—Harriet Hall and our fearless leader Steve Novella. Before the panel, we all gave brief talks on areas that we consider important. As you might expect, I chose to give a brief introduction to what I like to call “quackademic medicine,” defined as the pseudoscientific medicine being practiced and studied in academic medical centers. As I like to do in order to drive the point home about just how bad it’s become, I chose a couple of truly egregious examples of just how much quackery has infiltrated medical academia. First, I mentioned how the Cleveland Clinic has embraced reiki, which, as I’ve described many times before, is in reality faith healing that substitutes Eastern mysticism for Christian beliefs. One example I used was this:

Yes, that is exactly what you think it is. It’s the official Twitter account of the Mayo Clinic promoting “energy therapies,” of which reiki is one of the most popular varieties. Basically, these are “therapies” in which it is claimed that the practitioner can either (1) manipulate the “life energy” fields of the patient (e.g., healing touch) or (2) channel “healing energy” into the patient from a source (e.g., reiki). And here was the Mayo Clinic promoting this magical mystical nonsense, linking to an article on its official website entitled Energy Therapies Offer Support in Healing for Cancer Survivors:

Reiki assists in balancing your physical, mental, emotional and spiritual well-being. The practitioner works with your body’s energy field to bring the energy into balance and create a sense of calm and peace.

Healing Touch uses the same principles with the goal of balancing the energy in and around your body. With Healing Touch, the practitioner also uses hand movements on or slightly above the body to clear and balance the energy fields around the person.

Not surprisingly, this promotion of mysticism (and, yes, “healing touch” and reiki are nothing but pure mysticism) provoked a reaction. One of these was from our very own Clay Jones:

They weren’t alone in protesting, either. I merely chose to highlight their Tweets because, of course, they’re part of the SBM family.

It was at this point that a physician named Michel Accad, MD, a cardiologist in San Francisco who has his own blog and has contributed to KevinMD.com. I didn’t recall ever having encountered him before. Certainly, a search of the blog didn’t find any mention of him before. However, in a nutshell, he expressed one common complaint about science-based medicine on Twitter:

This is an attitude that is at the very heart of how many misunderstand what Science-Based Medicine is. It is also a pernicious attitude that leads so many physicians to become and remain what Val Jones once so famously called them, “shruggies.” They know that modalities like reiki and the rest of “energy medicine,” homeopathy, acupuncture and the vast majority of traditional Chinese medicine, and much of what is being “integrated” into medicine under the rubric of “integrative medicine” range from being at best scientifically unsupported and at worst pseudoscientific or mystical nonsense, but they do nothing. They do not object. They do not complain. They shrug their shoulders.

If only Dr. Accad had simply expressed no more than a “shruggie” attitude. Instead, he decided to write a post entitled Is medicine a scientific enterprise? It’s a post full of straw man characterizations of SBM, appeals to “science isn’t enough,” and attacks on what he calls the “Flexnerian error of scientific medicine.” Because Dr. Accad perfectly encapsulates fallacious objections to SBM, I thought his post, which quotes several of those Tweets above as a jumping off point, would itself represent a good jumping off point to correct some of the misconceptions about SBM that are out there.

Is medicine a scientific enterprise?

Let’s start out with the title of Dr. Accad’s post, Is medicine a scientific enterprise? I counter that this in itself is the Burning Man-sized straw man around which all of Dr. Accad’s other straw men gather as it burns. No one argues that medicine is purely a scientific enterprise, which is the argument that Dr. Accad is countering. Even we here at SBM do not. None of this stops Dr. Accad from forging bravely ahead into the burning straw:

The outrage, of course, reflects the belief held by some that medical care should be “scientific” and purged of all “nonsense.” This idea is particularly popular among enthusiastic champions of a peculiar view of science as the sole and omnipotent purveyor of all real knowledge. Some of those involved in the tiff were undoubtedly of that persuasion.

But apart from holding sway in the minds of Richard Dawkins devotees, the notion that medicine should be a scientific undertaking pervades, to varying degrees, the entire health care community. After all, it is on the basis of this idea that Abraham Flexner boldly constructed the report which gave birth to our health care system a little over a century ago.

It was at this point that I was tempted to respond to Dr. Accad: “You say that as though it were a bad thing,” but I resisted the temptation. Oh, wait. No I didn’t. I actually did use that line when discussing this at the CFI conference. Never mind. Sarcasm aside (seriously, what does Richard Dawkins have to do with medicine, other than as part of a two-part documentary he did for the BBC back in 2007?), there’s more of the straw man, namely that supporters of SBM (like us) think that we should all be Mr. Spock rather than Dr. McCoy and approach patients with nothing more than pure science and logic and to crush all religion and spirituality in the process, like Richard Dawkins. It’s a caricature of SBM and its advocates, pure and simple, and an exceedingly lazy one at that.

Yes, we of “that persuasion” do argue that the best medical care should be based in science, because the fruits of applying science to medicine—something that really didn’t happen in a big way until around 150 years ago—are there for all to see. For example, infectious diseases are prevented by vaccines and cured by antibiotics. Infant mortality has plummeted, largely due to decreases in death due to infectious diseases that in Abraham Lincoln’s time it was not uncommon for a mother to bury four or more of her children. Even in 1900, one in seven children did not make it past age one. Life expectancy has increased markedly from that same time, when it was 46 for males and 48 for females. Now the same figures are 76 and 81, while death rates from heart disease and cancer have been falling. While certainly it’s not just science in medicine but also science in public health that brought clean water and better sanitation into cities that were cesspools of disease in the 19th century. There are many other examples how the application of science to medicine has benefited humanity enormously.

But what does “based in science” mean? There’s the rub, as they say. I will explain in a moment (hint: it doesn’t mean what Dr. Accad apparently thinks it means), but first let’s look at a bit more of Dr. Accad’s complaint:

Now, the idea that medicine should be a scientific enterprise–even to the slightest degree–is an erroneous idea. Medicine itself cannot be viewed as scientific for the simple reason that the aim of science is to acquire knowledge, whereas the aim of medicine is to heal. These are two distinct ends. Furthermore, a scientific enterprise is best carried out with dispassion: observation and experimentation. Healing, on the other hand, is best accomplished through personal involvement: caring.

Can you say “false dichotomy”? Sure, I knew you could. Of course, there’s a reason why Steve Novella called this blog “Science-Based Medicine” and not “Scientific Medicine” or “Medical Science” or some other variant thereof. It’s because the central thesis behind this blog is that the best medicine is based in science, not that medicine itself must be pure science. As Steve put it in the very post to appear in SBM way back in 2008:

The philosophy of this blog, at its core, is simple: Safe and effective health care is critical to to everyone’s quality of life; so much so that it is generally considered a basic human right. The best method for determining which interventions and health products are safe and effective is, without question, good science. Therefore it is in everyone’s best interest for health care to be systematically evaluated by the best science available.

And:

This is why the authors of this blog strongly advocate for science based medicine – the use of the best scientific evidence available, in the light of our cumulative scientific knowledge from all relevant disciplines, in evaluating health claims, practices, and products.

In other words, no, we do not claim that science is the “omnipotent purveyor of all real knowledge.” We do, however, claim that science is the best method of evaluating which medical claims, understandings, and treatments are safe and effective and which are not. In that sense, science is the best method to evaluate health claims. Certainly, no one, least of all Dr. Accad, has proposed a better method. Indeed, because medicine involves treating patients, an activity that involves taking into account each patient’s unique situation and values, treating patients can never be completely scientific. It’s not as though we haven’t discussed this many times before here. No one expects Dr. Accad to have read those posts or even to be aware of the existence of this particular blog, but I do expect him to think a little more deeply than 140-character Twitter posts. For instance, I know Clay Jones and Grant Ritchey understand this, but it’s the sort of thing that’s hard to say in 140 characters. Chastising the Mayo Clinic for promoting mystical faith healing as a valid treatment modality, however, is easily accomplished, and that’s what they did.

Unfortunately, Dr. Accad’s thoughts on the matter did not become clearer once he was freed of the tight constraints of Twitter, for he is positing a false dichotomy. Again, he seems to be arguing that one can’t apply science to medicine without losing the “human touch,” to which I respond, quite bluntly: What a load of fetid dingo’s kidneys! There is nothing—I repeat nothing—in science-based medicine that excludes caring for patients as a human being or being what so many proponents of “integrative medicine” like to refer to as a “healer.” Nothing! Let’s just put it this way: You can be an empathetic, caring doctor who uses nothing but science-baed medicine, and you can be a tone-deaf, uncaring practitioner who incorporates reiki, homeopathy, and all manner of pseudoscience into his practice. The two (practicing science-based medicine versus the empathy-based and potentially unscientific medicine that Dr. Accad seems to prefer and being an empathetic, caring physician) are not related other than in that those practicing unscientific medicine tend to have to come across as more empathetic and caring because that’s all they have other than placebo medicine!

Besides, in the end, effectiveness is what matters. If forced to choose between an empathetic “healer” who holds my hand as I die of sepsis and a wooden, distant doctor who saves my posterior with just the proper application of antibiotics and drainage of pus, guess which one I’ll pick. Sure, it would be nice to have both, and fairly often a patient can have both, but, again, the application of the correct science-based treatment that is effective trumps empathy for most people. Don’t get me wrong, empathy and caring are very important, but they offer little in terms of actual physical healing if the medicine being practiced has not been shown by science to be safe and effective. Without science-based medicine, a doctor can be as effective as doctors of hundreds or thousands of years ago; i.e., not very or possibly even worse than the disease. Such was the state of medicine, as full of empathetic “healers” as it was, for thousands of years before the evil Abraham Flexner made it all scientific a hundred years ago.

Of course, what Flexner actually did went beyond emphasizing science in the curriculum of medical schools. If you read the actual report, you’ll note that in its introduction Flexner decries the “overproduction of ill-trained” physicians by a “large number of commercial schools, sustained in many cases by advertising methods through which a mass of unprepared youth is drawn out of industrial occupations into the study of medicine.” In the end, Flexner made the following recommendations:

Reduce the number of medical schools (from 155 to 31) and poorly trained physicians;

Increase the prerequisites to enter medical training;

Train physicians to practice in a scientific manner and engage medical faculty in research;

Give medical schools control of clinical instruction in hospitals

Strengthen state regulation of medical licensure

Again, one wonders what Dr. Accad thinks is so bad about these recommendations:

Of course, this is not to say that scientific inquiry cannot inform doctors on the proper course of action. It certainly can, should, and does.

Which is all science-based medicine is, the idea that science must inform doctors on the proper course of action. That’s all Steve argued in the very first post on SBM and all we continue to argue: for a single science-based standard for evaluating medical claims. Unfortunately, Dr. Accad goes off the deep end right after:

But scientific inquiry can only be subordinate to medical care. It is because one cares for the patient that one seeks the best material ways to cure or treat the body, and scientific knowledge provides valuable information in that regard.

It was at this point that I as scratching my head with a hearty “WTF is this guy talking about?” What on earth is he referring to about scientific inquiry being subordinate to medical care? After all, when it comes to clinical trials (i.e., scientific inquiry), whether Dr. Accad realizes it or not, scientific inquiry is already subordinate to medical care. Medical ethics demands no less. That’s why it’s unethical to do a randomized controlled clinical trial of vaccinated versus unvaccinated children. It would do harm to the children in the unvaccinated arm, who would not receive the proper medical treatment to reduce their risk of deadly disease. That’s why we’re forced to rely on epidemiological studies to study vaccines and that’s why the only randomized controlled clinical trials of vaccines these days involve adding a vaccine to the existing schedule versus placebo, so that both experimental groups get at least the standard of care. That’s why cancer chemotherapy trials testing a new drug versus only placebo are becoming rarer and rarer; instead such trials are usually standard of care plus new drug versus standard of care plus placebo. Again, both groups get at least the standard of care. That’s what the entire concept of clinical equipoise is about, namely that there has to be genuine uncertainty about which treatment is better before a clinical trial (scientific inquiry) is warranted. In that way, scientific inquiry is and will always be subordinate to medical care.

But that’s not what Dr. Accad is talking about, as you will see.

Medicine and the nature of science

Dr. Accad’s little diatribe against “scientism” in medicine—which, let’s face it, is what he’s railing against, although he doesn’t actually use the word—would be bad enough, given the straw men torched by just the halfway point. In fact, I’m surprised he didn’t use the word, given that his of critics of “complementary and alternative medicine” (CAM) and “integrative medicine” as believing that science is the “omnipotent purveyor of all real knowledge” is as good a definition of scientism when used as a pejorative (as it almost always is) by advocates of pseudoscience as I’ve ever seen. Unfortunately, Dr. Accad’s understanding of science is—shall we say?—not exactly robust:

First, we should recognize that biomedical science is only scientific in a limited way. When, at the dawn of the modern era, science separated itself from philosophy to take on a decidedly empirical cloak, the human observer could no longer properly be the subject of scientific inquiry, except in an indirect manner. And where physics and chemistry have been able to uncover “laws” of nature, biomedical science generally limits itself to making tentative, statistical predictions on human data aggregates—populations.

Causality in physics (notwithstanding its Humean objections) is not the same as causality in biology, and is even less related to causality in human affairs. Medical care is a pursuit of health for the good of the another human being, an individual person. That person exists in and expresses a contextualized reality: Mrs. Jones is not a 76-year old woman with cancer, except as a shorthand identification. Mrs. Jones is a being of a rational, self-determining nature and, strictly-speaking, incomparable to any other 76-year-old woman with the same cancer. The scientifically “proven” benefit or ineffectiveness of treatment X is never proven in the case of Mrs. Jones.

Biomedical sciences aren’t as scientific as physics? At the risk of repeating myself, what a load of fetid dingos’ kidneys! Biomedical sciences are based on chemistry, which is based on physics, because all life is chemistry! Just because there is considerably more variability repeated observations in biology and biomedical sciences than there is in physics does not make biology any less scientific than physics. As for “laws” of nature, scientific laws are generally of the sort that can be reduced to simple equations, such as E=mc2. In contrast, a scientific theory usually seeks to synthesize a body of evidence or observations of a particular phenomenon. It is, as Jacob Silverman put it, a “grander, testable statement about how nature operates” that, although not reduceable to a pithy statement or equation, “does represent something fundamental about how nature works.”

And guess what? There are theories in biology and medicine that were derived from those very “tentative statistical predictions” on populations. There’s the theory of evolution, for example, which infuses all biological science, as well as phenomenon in medicine such as the evolution of bacterial resistance to antibiotics and tumor cell resistance to chemotherapy. There’s the germ theory of disease (of course), a major advancement in the late 1800s from which flowed much of the initial success of scientific medicine. Over time, other theories emerged, such as the theories governing molecular biology, which lead to theories about the genetic causes of diseases ranging from inborn errors of metabolism to cancer.

Nor does SBM conflict with patient autonomy, as Dr. Accad’s example of Mrs. Jones, the 76 year old woman with cancer, implies. Indeed, as I’ve argued time and time again, SBM is necessary for true patient autonomy. It is because Mrs. Jones is a rational, self-determining human being that she deserves the best information we as physicians have available about her disease, the treatments available, the risks and benefits of these treatments, and the pros and cons of these treatments relative to each other as the basis to make a collaborative decision with her physician on how to treat her disease. Without that information, she can never provide true informed consent, only misinformed consent (as I like to put it). And, yes, Dr. Accad, science really is the best means of answering these questions in medicine. (If a better means exists, certainly Dr. Accad certainly hasn’t suggested it—just like every other doctor defending quackery like reiki on the basis of “science isn’t enough.”) It is true that Mrs. Jones brings her own values and unique situation to the interaction with her physician. For instance, she might have decided that at 76 she values quality of life over remaining quantity of life and therefore doesn’t want to suffer harsh side effects or take major risks. Alternatively, she might desperately want to live long enough to see her grandchild marry and be willing to take chances to see that happen, if medicine can make it possible. However, she cannot properly incorporate her life values and experience into the question if someone is telling her that magic do her good, particularly if that person is wearing a white coat and is speaking with the authority society gives physicians for their knowledge of medicine.

Now, those of you sympathetic to SBM, be sure to put down your drink if you have one and swallow whatever it is you’re drinking. I don’t want to be responsible for any ruined keyboards. You have been warned.

Dr. Accad argues next:

Secondly, to circumscribe medical care inside the realm of science limits the autonomy of the patient. Perforce, “scientific medicine” in the Flexnerian sense separates the physician from the patient, because the latter becomes an object in (or a subject of) the scientific enterprise, and therefore, at some level, must be deemed incapable of judging the value of the care received: no one asks the falling apple if it would prefer to be considered under the law of universal gravitation or under the general theory of relativity.

The Flexnerian notion of scientific medicine, then, brings to the fore the “information asymmetry” in the doctor-patient relationship and justifies State intervention by way of licensing laws. In turn, licensing laws give credence to and materialize this asymmetry. Patients, as object of scientific medicine, can no longer freely choose their care as the State intervenes to ensure safety and efficacy according to objective, scientific norms.

The claim that “Flexnerian” medicine causes the patient to become an object of the scientific enterprise and incapable of judging the value of the care received is a straw man so massive that, were it to be burned, not only could it be seen from space but the smoke it would produce would single-handedly accelerate global warming by several decades. In fact, it is science that has shown that human perceptions alone are unreliable and that the various effects that are often bundled together as shorthand under the term “placebo” effects do mean that patients will frequently feel better subjectively after an intervention that can’t do anything physiological, such as homeopathy. I would argue that it is the job of a physician to do better than that whenever possible, as placebo effects are an incredibly low standard to hold ourselves to.

The real problem with Dr. Accad’s attitude, however, boils down to an issue that he did not really address: What is the obligation of a physician with respect to his or her recommendations to patients? All his misunderstanding of what advocates of science-based medicine actually argue and his apparent lack of understanding how biomedical science actually works are painful for me to read, but what’s very noticeable by its absence, other than in that Tweet, is upon what Dr. Accad thinks we should base our recommendations to patients on, if not the results of biomedical science? To be fair, Clay did try to bring up this issue of patient autonomy and the problematic ethics of not providing science-based information to patients and, worse, of offering mystical pseudoscience (like “energy medicine”) to patients as though it had scientific validity:

Unlike Dr. Accad, I do have a big problem with physicians and hospitals, particularly academic medical centers, peddling unadulterated nonsense like reiki to patients because that’s not what patients come to us for. They come to us for our best evidence-based recommendations, and, as Clay and I have argued, without that they cannot have true autonomy to give informed consent because, lacking that and in particular if the information they are given is just plain wrong (or, as Clay put it, unadulterated nonsense), they lack the necessary information to make an informed decision. Embracing and recommending pseudoscience represents a profound betrayal of our patients.

Think about it this way. Medicine has historically only been as good as the science behind it. Back when Hippocrates and his followers were revolutionizing Greek medicine, they made a number of advances, not the least of which was overturning the widespread belief that disease was caused by the gods or supernatural forces, thus introducing the concept that disease could be treated once it was understood how it comes about. Unfortunately, Hippocrates and his followers could go no further because they didn’t have a testable scientific framework into which they could put their observations. Hippocrates posited humoral theory, in which disease was thought to be the result of imbalances in four “humors.” Traditional Chinese medicine had a similar concept. True, they substituted five elements for four humors, but the concept, namely that disease was the result of an “imbalance” of these humors or elements, was very similar.

For many hundreds of years afterward, medicine remained more or less stagnant. Bleeding, cupping, violent purging, endless botanical abstracts, heavy metals, and the like reigned as the preferred treatments, with all sorts of learned treatises written on the benefits and harms, the pros and cons, of each. Advances were few and far between until 1800s, when medicine began to embrace science. Indeed, Lewis Thomas in his book The Youngest Science, dated the beginning of the era of scientific therapeutics to the beginning of the antibiotic era in the 1930s, noting that, until the discovery of chemotherapy for infections, clinicians quite literally had almost nothing to offer the patient other than rest, good nursing care, and draining abscesses there were any. He had a point, although the earlier discovery of insulin could just as easily been used as a starting point.

It is true that there are many problems with science-based medicine, and we have written about quite a few of them right here on this very blog over the last seven and a half years. One of the worst is how the reimbursement model has changed to the point where doctors are disincentivized from spending more time with their patients, which makes it very difficult to actually deliver that human touch, to be the healer that Dr. Accad so pines for. However, to paraphrase Ben Goldacre, just because there are flaws in aircraft design does not mean that flying carpets work, and just because there are problems with science-based medicine does not imply that we should embrace or tolerate physicians recommending unadulterated nonsense like reiki to patients to fix these problems. Dr. Accad claims that “scientific medicine is truly nonsense,” but it’s clear that he does not know what scientific medicine actually is, which is why he constructs a straw man version of it that is nonsense. Contrary to what people like Dr. Accad and Dr. David Katz argue, it is not necessary to reject science and embrace pseudoscience in order to be a caring, empathetic holistic healer. Physicians can—and should—be such healers using science-based medicine.

In which I steal a title: Is medicine a scientific enterprise? David Gorski